UK wide survey on the prevention of post-ERCP pancreatitis.

ENDOSCOPY

OPEN ACCESS

RESEARCH

UK wide survey on the prevention
of post-ERCP pancreatitis

Mina S Hanna/ Andrew J Portal/ Ashwin D Dhanda,^
Robert Przemioslo^

► Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
flgastro-201 3-1 00323).

^Department of Gastroenterology
and Hepatology, Bristol Royal
Infirmary, University Hospitals
Bristol NHS Trust, Bristol, UK
^School of Clinical Sciences,
University of Bristol, Bristol, UK
^Department of
Gastroenterology, Frenchay
Hospital, North Bristol NHS
Trust, Bristol, UK

Correspondence to

Dr Mina S Hanna, Department
of Gastroenterology and
Hepatology, Bristol Royal
Infirmary, Upper Maudlin Street,
Bristol BS2 8HW, UK;
Mina.Hanna@nhs.net

Received 5 March 2013
Revised 8 August 2013
Accepted 14 August 2013
Published Online First
3 September 2013

To cite: Hanna MS,
Portal AJ, Dhanda AD, et al.
Frontline Gastroenterology
2014;5:103-110.

ABSTRACT

Objective In 2010, the European Society of
Gastrointestinal Endoscopy delivered guidelines
on the prophylaxis of postendoscopic retrograde
cholangiopancreatography (post-ERCP)
pancreatitis (PEP). These included Grade A
recommendations advising the use of
prophylactic pancreatic stent (PPS) and non-
steroidal anti-inflammatory drugs (NSAIDs) in
high-risk cases. Our study aim was to capture the
current practice of UK biliary endoscopists in the
prevention of PEP.

Design In summer 201 2, an anonymous online
1 5-item survey was emailed to 373 UK consultant
gastroenterologists, gastrointestinal surgeons and
radiologists identified to perform ERCP.
Results The response rate was 59.5% (222/373).
Of the respondents, 52.5% considered ever using
PPS for the prevention of PEP. PPS users always
attempted insertion for the following procedural
risk factors: pancreatic sphincterotomy (48.9%),
suspected sphincter of Oddi dysfunction (46.5%),
pancreatic duct instrumentation (35.9%),
previous PEP (25.2%), precut sphincterotomy
(8.5%) and pancreatic duct injection (7.8%).
Prophylactic NSAID use was significantly
associated with attempts at PPS placement
(p<0.001). 64.1 % of non-PPS users cited a lack
of conviction in their benefit as the main reason
for their decision. Self-reported pharmacological
use rates for PEP prevention were: NSAIDs
(34.6%), antibiotics (20.6%), rapid intravenous
fluids (1 3.2%) and octreotide (1 .6%). 6%
routinely measured amylase post-ERCP.
Conclusions Despite strong evidence-based
guidelines for prevention of PEP, less than 53% of
ERCP practitioners use pancreatic stenting or
NSAIDs. This suggests a need for the
development of British Society of
Gastroenterology guidelines to increase
awareness in the UK. Even among stent users,
PPS are being underused for most high-risk cases.
Prophylactic pharmacological measures were
rarely used as was routine post-ERCP serum
amylase measurement.

BACKGROUND

Postendoscopic retrograde cholangiopan-
creatography (post-ERCP) pancreatitis
(PEP) is the most common and serious
comphcation of ERCP In a systematic
review of 16 855 unselected patients
undergoing ERCI^ the incidence of PEP
was approximately 3.5%. While its sever-
ity is most commonly mild or moderate,
approximately 11% of cases are severe.
The overall PEP mortality rate was 3.1%.^

Numerous patient-related and
procedure-related risk factors for the
development of PEP have been identi-
fied.^"^ Much effort has been made to
avoid this iatrogenic complication, par-
ticularly in these high-risk patients.

Prophylactic pancreatic stenting and
pharmacological measures have been
used to reduce the incidence and severity
of PEP In 2004, a meta-analysis of five
randomised controlled trials (RCTs)
involving 481 patients demonstrated that
patients without prophylactic pancreatic
stent (PPS) had a threefold higher odds
of developing pancreatitis compared with
the stent group (15.5% vs 5.8%; OR 3.2,
number need to treat (NNT) 10).^ A sub-
sequent meta-analysis of eight RCTs (656
patients) and 10 non-randomised trials
(4904 patients) showed similar results.^

A meta-analysis of four RCTs (7678
patients) showed that patients who
received intrarectal non-steroidal anti-
inflammatory drugs (NSAIDs) in the peri-
procedural period were 64% less likely to
develop pancreatitis and 90% less likely
to develop moderate to severe pancrea-
titis (NNT=15).^ Recently, a multi-centre
RCT of 605 patients showed significant
benefit in high-risk cases. ^

In 2005, a postal survey returned by 49
expert North American biliary endosco-
pists showed that 96% used PPS in
selected high-risk cases.^

Hanna MS, etal. Frontline Gastroenterology 2014;5:103-110. doi:10.1 136/flgastro-20 13-1 00323

103

ENDOSCOPY

In June 2009, a survey completed by 141 partici-
pants attending a European therapeutic endoscopy
course held in Belgium demonstrated that 78.7% of
respondents inserted PPS.^^ Statistical analysis showed
that measurement of incidence of PEP (p =0.005) and
an annual hospital ERCP volume of more than 500
ERCPs (p = 0.030) v\^ere significantly associated v\^ith
prophylactic pancreatic stenting.^^

In June 2010, European Society of Gastrointestinal
Endoscopy (ESGE) guidelines v\^ere released advising
on indications for PPS insertion, stent characteristics,
follov\^-up timing and methods as v\^ell as making
recommendations on pharmacoprophylaxis and
routine post-ERCP amylase measurements in pro-
posed day case procedures.

Our main study aim v\^as to capture current practises
of UK bihary endoscopists in the prevention of PEP in
the light of these guideUnes.

Furthermore, we aimed to ascertain v\^hether any
additional operator factors v\^ere associated v\^ith the
decision to introduce PEP prophylaxis measures.

METHODS

Participant selection

The bihary endoscopists v\^ere identified by contacting
every UK Hospital's Endoscopy department in all 10
English Service Health Authorities, Northern Ireland,
Scotland and Wales to elicit v\^hether and by v\^hom
ERCP v\^as being performed. In all, 373 bihary endos-
copists (consultant gastroenterologists, gastroenter-
ology surgeons and radiologists) v\^orking at 171
different UK hospitals v\^ere identified. The partici-
pants' email addresses v\^ere obtained from the British
Society of Gastroenterology directory, and if not
members were found using the National Health
Service (NHS) mail search function, the relevant insti-
tution v\^ebsite or by contacting the participants' insti-
tution IT department/secretarial support team.

Study design and administration

A 15 -item online questionnaire (see online supple-
mentary appendix A) v\^as developed based on the
current ESGE guidelines and emailed to the study par-
ticipants betv\^een 30 May 2012 and 14 June 2012.
All relevant studies and guidelines referred to in the
introduction had been published at this time. All
study participants v\^ere emailed the identical weh link
to protect anonymity. No financial or other incentives
v\^ere offered for completion of the survey. A reminder
email v\^as sent to non-responders betv\^een 2 July
2012 and 9 July 2012.

Statistical analysis

A linear stepv\^ise multiple regression analysis v\^as per-
formed to ascertain factors associated v\^ith PPS use.
p Values of <0.05 v\^ere considered statistically signifi-
cant. The remainder of the survey findings are demon-
strated using descriptive statistics.

RESULTS

Respondent demographics

In all, 222 of the 373 UK based bihary endoscopists
completed the survey (59.5%). The majority of survey
respondents had been performing ERCP for more
than 10 years (n=182; 82.4%). Most respondents had
an annual procedure volume of 75-150 ERCPs. The
respondents' full demographics subgrouped by PPS
use and NSAID use are displayed in table 1.

The number of PPS and NSAID users is displayed as
a percentage of the total respondents for each corre-
sponding subdivision.

PPS use

Of the 219 survey respondents, v\^ho stated v\^hether
they used PPS or not, 115 (52.5%) inserted PPS,
v\^hile 104 (47.5%) never considered inserting them.

In the PPS user group, the individuals stated they
aWays considered placing PPS for the follov\^ing risk
factors (figure 1): pancreatic sphincterotomy (48.9%),
suspected sphincter of Oddi dysfunction (46.5%),
pancreatic duct instrumentation (35.9%), previous
PEP (25.2%), precut sphincterotomy (8.5%) and pan-
creatic duct injection (7.8%).

The majority of PPS users never inserted pancreatic
stents for the follov\^ing PEP risk factors: trainee involve-
ment in case (58.9%), patient age less than 60 (58.8%),
female gender (56.7%) and balloon dilatation of the
biliary sphincter (56.2%).

Factors associated with PPS use

We performed a linear stepw^ise multiple regression ana-
lysis to investigate v\^hether years of ERCP experience,
annual personal ERCP volume. Service Health
Authority, prophylactic pharmacotherapy use (NSAIDs,
antibiotics, intravenous fluids, octreotide) and routine
day case post-ERCP amylase measurement v\^ere asso-
ciated v\^ith PPS insertion (table 2). Only peri-procedural
NSAID use v\^as associated v\^ith prophylactic pancreatic
stenting at a statistically significant level (p<0.001).

Stent characteristics

Of PPS users, 114 respondents stated the type of stent
they used (figure 2). In all, 38 (33.3%) used single-
flanged straight stents exclusively. A further 30 (26.3%)
employed unflanged pigtail stents, v\^hile 21 (18.4%)
used single-flanged pigtail stents. A total of 6 (5.3%)
endoscopists used straight unflanged stents.

Of 113 bihary endoscopists v\^ho indicated the diam-
eter of their PPS (figure 3), the majority (n=80,
70.8%) used 5F stents exclusively.

There v\^as a v\^ide variation in the length of the pan-
creatic stents used among the 105 respondents to this
question (table 3).

Stent clearance follow-up methods and timing

In PPS users, the majority (n=79; 71.8%) performed
a single abdominal radiograph to ensure spontaneous

104

Hanna MS, etal. Frontline Gastroenterology 2014;5:103-110. doi:10.1 136/flgastro-201 3-1 00323

ENDOSCOPY

Table 1 Overview of survey respondents' demographics (subgrouped by PPS and NSAID use)

All respondents PPS users NSAID users

Years of ERCP experience n=221 n=1 14 n=71

0-5 6 (2.7%) 4/6 (66.7%) 3/6 (50.0%)

6-10 33 (14.9%) 20/33 (60.6%) 13/33 (39.4%)

>10 182 (82.4%) 90/182 (49.5%) 55/182 (30.2%)

Annual ERCP volume n=221 n=115 n=71

<75 13(5.9%) 4/13(30.7%) 3/13(23.1%)

75-150 130 (58.8%) 71/130 (54.6%) 47/130 (36.1%)

1 50-300 75 (33.9%) 38/75 (50.6%) 20/75 (26.6%)

>300 3 (1.4%) 2/3(66.6%) 1/3(33.3%)

Service Health Authority n=221 n=115 n=71

East of England 16(7.2%) 10/16(62.5%) 5/16(31.3%)

East Midlands 1 5 (6.8%) 9/1 5 (60.0%) 6/1 5 (40.0%)

London 28 (1 2.7%) 1 7/28 (60.7%) 8/28 (28.5%)

North East 1 2 (5.4%) 7/1 2 (58.3%) 2/1 2 (2.8%)

North West 23 (10.4%) 1 1/23 (47.8%) 1 1/23 (47.8%)

South Central 18(8.1%) 8/18(44.4%) 11/18(61.1%)

South East Coast 1 1 (5.0%) 3/1 1 (27.2%) 2/1 1 (18.2%)

Southwest 29(13.1%) 1 1/29 (37.9%) 8/29 (27.5%)

West Midlands 16(7.2%) 12/16(75.0%) 4/16(25.0%)

Yorkshire and the Number 13 (5.9%) 6/13 (46.2%) 3/13 (23.1%)

Northern Ireland 10 (4.5%) 6/10 (60.0%) 6/10 (60.0%)

Scotland 16(7.2%) 5/16(31.3%) 4/16(25%)

Wales 14(6.3%) 10/14(71.4%) 3/14(21.4%)

ERCP, endoscopic retrograde cholangiopancreatography; NSAID, non-steroidal anti-inflammatory drug; PPS, prophylactic pancreatic stent.

pancreatic stent passage. In all, 6 (5.4%) respondents
performed serial abdominal radiographs to check for
stent passage, 17 (15.5%) respondents arranged for
endoscopy to remove PPS without prior abdominal
x-ray while 8 (7.3%) respondents did not follow-up
stent clearance at all (figure 4).

Overall, 84 biliary endoscopists indicated the
number of days until obtaining their final abdominal
x-ray prior to attempting stent retrieval (figure 5).
Most respondents (n=37, 44.0%) performed their
last abdominal radiograph 11-14 days post stent inser-
tion. After this time, endoscopic retrieval was under-
taken where the stent was retained.

Reasons for non-PPS use

Of the 104 respondents who did not use PPS, 92
stated their reasons for not using them. Several
respondents chose multiple reasons. Overall, 59
(64.1%) respondents were not convinced of the pro-
tective effect of PEP in preventing PEI^ whereas
38 (41.3%) felt that they had insufficient experience
in placing pancreatic stents, 23 (25%) were concerned
about the increased risk of PEP in cases of failed
prophylactic stent insertion and 12 (13%) respondents
did not have pancreatic stents available to them in
their institution. Thirteen gave other reasons with the
most common one (nine respondents) being that PPS

young age (<60)
female gender
previous PEP
suspected SOD
difficult cannulation(>5 attempts)
Biliary sphincter dilatation
traumatic biliary sphincterotomy
pre-cut sphintcerotomy
pancreatic duct instrumentation
pancreatic duct injection(l or more)
pancreatic sphincterotomy
trainee involvement in case

[111

1 I I

1 1 I

' . ' ' ' ' '

1 ■ I

' ' I I I

— 1 — 1 — 1 — '

1 ■ 1 1 ■ 1 ♦ '

1

I'll' r

1 :

_ 1 1 1

1 1 ■

1 I I ' 1

' I

I ' ' ' 1

1 1 1 1 1 1 1

P \ 1 } 1 \ 1 \ 1

H never
■ 1-25%
y 26-50%
H 51-75%
y 76-99%
y always

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 1 Percentage of endoscopic retrograde cholangiopancreatographies (ERCPs) with prophylactic pancreatic stent placement
by post-ERCP pancreatitis (PEP) risk factor. The total number of responses for each PEP risk factor ranged from 89 to 108.

Hanna MS, etal. Frontline Gastroenterology 2014;5:103-110. doi:10.1 136/flgastro-20 13-1 00323

105

ENDOSCOPY

Table 2 Multiple logistic regression analysis of factors possibly
associated with prophylactic pancreatic stents use

Factor p Value

Years of ERCP experience 0.404

Annual personal ERCP volume 0.512

Service Health Authority 0.725

NSAID use <0.001

Octreotide use 0.079

Antibiotic use 0.856

Intravenous fluid use 0.647

Routine postprocedure amylase measurement 0.948

ERCP, endoscopic retrograde cholangiopancreatography;
NSAID, non-steroidal anti-inflammatory drug.

insertion was unlikely to significantly improve their
PEP rate as it was already very low

Pharmacotherapy use and post-ERCP amylase
measurement

In all, 72 respondents (34.6%) used NSAIDs in the
prophylaxis of PEI^ whereas 136 (65.4%) did not use
them. Rapid intravenous fluids were employed by 25
respondents (13.2%). Three respondents used octreo-
tide. Antibiotics for the prophylaxis of PEP were rou-
tinely prescribed by 41 respondents (20.6%). Table 4
displays the survey respondents' use of pharmacopro-
phylaxis and routine post-ERCP amylase measurement
subgrouped by PPS use.

DISCUSSION

This study represents the first survey to date of the
practice of UK hepatobiUary endoscopists in using
strategies to prevent PEP

Surprisingly, only about a half of UK biUary endos-
copists considered prophylactic pancreatic stenting
and only a third used NSAIDs despite the introduc-
tion of the ESGE guidelines and Grade A recommen-
dations existing for both.

By contrast, a similar North American survey^
found that 96% used PPS and an EU survey found
that 78.7% of survey respondents inserted them.

Our study had more respondents compared with
the other two studies (222, 141 and 49, respectively).
This difference may account for some of the variation
and it may therefore be the case that our figure of
approximately 50% stent users is more representative
of the true clinical practice.

It appeared that the biliary endoscopists who used
PPS underused them for several high-risk interven-
tions such as Sphincter of Oddi Dysfunction (SOD)
and pancreatic endotherapy.

While the majority of respondents (70.0%)
employed 5F stents exclusively as recommended by
the ESGE guidelines, there was a wide variation in the
stent length and design being used. This is perhaps
understandable because although the ESGE guidelines
currently advise the use of short 5F pancreatic
stents, no recommendation on the exact ideal stent
length or design is made. This may be because most
of the characteristics of the 'ideal' PPS are currently
unknown.

Most PPS users (77.2%) performed an abdominal
x-ray prior to attempting stent retrieval, while a sig-
nificant number proceeded straight to endoscopy
(15.5%). In both groups the timing varied greatly. The
ideal time for PPS to remain in situ is currently
unknown. It is unclear whether the protective effect
of prophylactic pancreatic stenting is reversed if the
pancreatic stent is removed too early although it is
likely that beneficial effects occur early after ERCP
Sherman et al^^ found that when PPS were removed
immediately following precut sphincterotomy, the risk
of PEP was significantly increased compared with
stents that remained in situ for 7-10 days (2.2% vs
21.3%; p= 0.004). Two other studies showed that
early stent passage at 24 and 72 h respectively was not
a significant risk factor for the development of PEP
suggesting that physical removal of the stent may be a
risk factor for provoking pancreatitis.^^ Moffatt

50

unflanged single-flanged unflanged single-flanged Other stent Combination
straight stent straight stent pigtail stent pigtail stent type of stents

Figure 2 Survey respondents' stent type used.

106

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ENDOSCOPY

-12-

Figure 3 Survey respondents' stent diameter used.

et al^^ found in their retrospective study of 230
patients undergoing endoscopic PPS removal that 3%
developed acute pancreatitis.

Pancreatic stents that remain in situ for more than
2 v\^eeks have been shov\^n to increase the risk of PEP
more than five times compared v\^ith patients v\^ith
spontaneous stent elimination at 2 v\^eeks or less^^
v\^hile it is also knovs^n that they confer an increased
risk of stent-induced pancreatic duct changes and sub-
sequently chronic pancreatitis.^^

ESGE guidelines currently recommend obtaining
follov\^-up imaging 5-10 days post stent insertion
W\xh prompt retrieval if they are still found to be in

situ

11

Our study shov\^ed a correlation between pancreatic
stent use and the use of NSAIDs at a statistically sig-
nificant level (p<0.001). This may be related to a
higher case load of patients at increased risk of PEP
among these biliary endoscopists or simply their
increased av\^areness of methods of PEP prevention.

Current ESGE guidelines recommend the use of
100 mg diclofenac or indomethacin via the intrarectal
route immediately before or after ERCP to reduce the
incidence of PEP^^ Approximately a third of our
respondents used NSAIDs. It is notev\^orthy that in the
survey by Dumonceau et al^^^ only 16.3% of

Table 3 Survey respondents stent length used

Stent length

Number of respondents (%) n=105

3 cm only

25 (23.8%)

4 cm only

16(15.2%)

5 cm only

20(19.0%)

6 cm only

5 (4.8%)

7 cm only

1 (1.0%)

3 and 4 cm

6 (5.7%)

3 and 5 cm

13 (12.4%)

4 and 5 cm

4 (3.8%)

5 and 7 cm

5 (4.8%)

Other combinations

10 (9.5%)

respondents used NSAIDs. At the time this v\^as attrib-
uted to insufficient scientific evidence supporting
their use. The higher number of NSAID users in our
survey might be explained by the results of subsequent
RCT. This RCT of 602 patients undergoing ERCP
shov\^ed that even in patients at increased risk of devel-
oping PEP, intrarectal indomethacin v\^as effective in
reducing its incidence.^

A prospective Australian study of 263 ERCPs shov\^ed
that a serum amylase level of less than 1.5 times the
upper limit of normal measured 4 h post-ERCP had a
negative predictive value of 100% in excluding PEP^^
The ESGE guidelines recommend measuring serum
amylase levels post-ERCP in day case patients to facili-
tate safe discharge. Interestingly, only 6% of our
respondents performed this practice in their day case
patients prior to discharge. A potential reason may be
that it can be impractical to process blood results in suf-
ficient time to make this practical especially considering
current bed pressures in the NHS.

The tv\^o main reasons cited among our survey
respondents for not inserting PPS in high-risk patients
w^ere lack of conviction in their benefits and insuffi-
cient experience in inserting them. This is interesting
given published guidelines existing v\^ith high grade
evidential support for the interventions.

Another reason cited for non-insertion v\^as the per-
ception of a lov\^ incidence of PEP in non-PPS/NSAID
users. Unfortunately, data are lacking for postproce-
dural complications such as PEP otherv\^ise it might be
of interest to try and correlate interventions v\^ith real
practice incidence of these complications or hospital-
isation post-ERCP Prophylactic pancreatic stenting has
been shov\^n to reduce the incidence of PEP and
reduce its severity v\^hen it occurs.^^ It could therefore
be the case that even endoscopists v\^ith a lov\^ PEP rate
may benefit from inserting PPS.

Our study may be potentially susceptible to non-
responder and recall bias. Non-respondents may have
had less interest in methods of PEP prevention. It is
conceivable that the respondents selected gave v\^hat

Hanna MS, etal. Frontline Gastroenterology 2014;5:103-110. doi:10.1 136/flgastro-20 13-1 00323

107

ENDOSCOPY

Table 4 Pharmacoprophylaxis use and post-ERCP amylase measurement (subgrouped by PPS vs non-PPS use)

Pharmacoprophylaxis use

Overall

PPS users

Non-PPS users

Yes

No

Yes

No

Yes

No

NSAID

72 (34.2%)

136 (65.4%)

53 (47.3%)

59 (52.7%)

18 (19.1%)

76 (80.9%)

Antibiotics

41 (20.6%)

158 (79.4%)

17 (17.2%)

82 (82.8%)

24 (24.2%)

75 (75.8%)

Intravenous fluids

25 (13.2%)

165 (86.8%)

16 (16.2%)

83 (83.8%)

9 (10.0%)

81 (90.0%)

Octreotide

3 (1.6%)

185 (98.4%)

0 (0%)

97 (100%)

3 (3.3%)

87 (96.7%)

Post-ERCP amylase measurement

13 (6.0%)

205 (94.0%)

6 (5.3%)

108 (94.7%)

7 (6.9%)

94 (93.1%)

The overall number of respondents included respondents who did not declare whether they used PPS or not.

ERCP, endoscopic retrograde cholangiopancreatography; NSAID, non-steroidal anti-inflammatory drug; PPS, prophylactic pancreatic stent.

they thought to be the 'correct' answer rather than
what they do in their own practice. On balance, our
results represent the best-case scenario in terms of PPS
insertion and pharmacoprophylaxis use. Furthermore,
although all of the selected respondents were practis-
ing ERCP at a consultant level, it is unclear from our
survey whether they received specific training in
inserting pancreatic stents considering that over 40%
of respondents cited insufficient experience in pancre-
atic stenting for non-use. It may beneficial for future
trainees to attend mandatory Joint Advisory Group on
GI Endoscopy (JAG) accredited ERCP courses where
the indications of stents insertion as well as technical

aspects of insertion could be taught and demon-
strated. It could also be argued that due to the critical
importance of using NSAIDs and/or PPS in preventing
PEP that this could be added as Global Rating Scale
(GRS) auditable field such as the use of antibiotics for
incomplete drainage.

Although both NSAIDs^^ and PPS^^ have been con-
firmed to be independently effective in recent
meta-analyses, the most effective overall strategy is cur-
rently unknown. ESGE guidelines recommend the
routine use of intrarectal NSAIDs in low-risk cases and
PPS for high-risk cases. A recent meta-analysis of 29
studies (22 of pancreatic duct (PD) stents and seven of

H Abdominal Imaging prior to Endoscopy ■ Endoscopy without prior Abdominal Imaging
40 S7

1 day 2-5 days 5-7 days 7-10 days 11-14 days 15-21 days >21 days

Figure 5 Number of days to obtaining prophylactic pancreatic stents follow-up imaging/attempting stent retrieval.

108

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NSAIDs) showed that intrarectal NSAIDs alone were
superior to PD stents alone in preventing PEE^"^
However, as the authors acknowledge, these findings
are limited by the small number of studies assessed and
the indirect nature of the comparison.^"^ Furthermore, a
post hoc economic analysis of a single RCT showed that
intrarectal NSAIDs were more cost-effective than PPS.^^
Several large scale RCTs directly comparing NSAIDs

What is already known on this topic

► Postendoscopic retrograde cholangiopancreatography
(post-ERCP) pancreatitis (PEP) is the most common
and serious complication of ERCP

► Both prophylactic pancreatic stenting and peri-
procedural non-steroidal anti-inflammatory drug use
have been shown to significantly reduce the inci-
dence of PEP and their use is recommended by the
European Society of Gastrointestinal Endoscopy
guidelines.

What this study adds

► This represents the first UK wide survey of hepatobili-
ary endoscopist practices in reducing postendoscopic
retrograde cholangiopancreatography (post-ERCP)
pancreatitis (PEP).

► Approximately half of UK endoscopists performing
ERCP use prophylactic pancreatic stents, while a third
use non-steroidal anti-inflammatory drugs (NSAIDs)
as PEP prophylaxis.

► Despite strong evidence, the main reason cited for
not using pancreatic stenting is a personal belief of
their non-effectiveness in preventing PEP

► Prophylactic pancreatic stent use is associated with
peri-procedural NSAID use at a statistically significant
level, while years of ERCP experience, annual per-
sonal ERCP volume, UK region and routine post-ERCP
amylase measurement are not.

How might it impact on clinical practice in the fore-
seeable future

► There is evidence available that would facilitate safer
endoscopic practice in preventing postendoscopic
retrograde cholangiopancreatography pancreatitis.
Awareness of these data is significantly lower in the
UK than in Europe and the USA. It is possible that
European Society of Gastrointestinal Endoscopy guide-
lines are not used as terms of reference by UK endos-
copists and that British Society of Gastroenterology
guidelines might improve compliance.

versus PPS versus a combination of both are essential in
clarifying the optimal overall strategy to prevent PEP

In summary, prophylactic pancreatic stenting and
NSAID use although shov\^n to be effective in redu-
cing the incidence of PEP v\^ere underused among
UK biliary endoscopists. GuideUnes and evidence
already exists for these safer practice measures and
these data are important to stimulate debate and
increase av\^areness among practicing biliary endosco-
pists in the UK.

Acknowledgements We are indebted to our survey respondents
for kindly completing our survey.

Contributors MSH, AJP and RP w^ere involved in the concept
and design of the survey; MSH collected, assembled, analysed
and interpreted the data and vs^rote the manuscript; ADD
performed the multiple regression analysis; AJP and RP
supervised the analysis, interpreted the data, critically revievs^ed
and edited the manuscript. All authors have approved the final
version of the article, including the authorship list. MSH
accepts responsibility for the integrity of the work as a whole
from inception to the published article.

Competing interests None.

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